Provider Demographics
NPI:1649218660
Name:FAY-LEBLANC, RENEE (MD)
Entity Type:Individual
Prefix:
First Name:RENEE
Middle Name:
Last Name:FAY-LEBLANC
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:180 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-2957
Mailing Address - Country:US
Mailing Address - Phone:207-874-2141
Mailing Address - Fax:207-874-2164
Practice Address - Street 1:180 PARK AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-2957
Practice Address - Country:US
Practice Address - Phone:207-874-2141
Practice Address - Fax:207-874-2164
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME017048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME432190199Medicaid
MEME224202Medicare PIN
MEP00363132Medicare PIN
MEME2242Medicare PIN
ME432190199Medicaid
MEME224201Medicare PIN
MEP00928533Medicare PIN
MEME224203Medicare PIN
ME970027741Medicare PIN